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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208826
Report Date: 03/12/2025
Date Signed: 03/12/2025 01:50:56 PM

Document Has Been Signed on 03/12/2025 01:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SHERWOOD ELDERLY CARE FACILITYFACILITY NUMBER:
157208826
ADMINISTRATOR/
DIRECTOR:		BARAJAS, JUDITHFACILITY TYPE:
740
ADDRESS:2204 SHERWOOD AVETELEPHONE:
(661) 220-6647
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93304
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
03/12/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:14 PM
MET WITH:Administrator Judith BarajasTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a complaint investigation. During the course of the investigation, LPA observed deficiencies. LPA conducted a Case Management to address the deficiencies. LPA met with Administrator Judith Barajas.

During the course of the investigation of complaint 24-AS-20241213102753, LPA conducted a records review and did not locate a Hospice Care Plan for R1. LPA also reviewed R1's LIC 602 which did not have a primary or secondary diagnosis. LIC 602 did indicate the reason R1 was on hospice.

Refer to 809d

A copy of this report with plans of correction and appeal rights was provided to Administrator.

Alexandria WaltonTELEPHONE: (559) 246-0128
Shawna DoucetteTELEPHONE: (559) 580-4595
DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2025 01:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: SHERWOOD ELDERLY CARE FACILITY
FACILITY NUMBER: 157208826

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2025
Section Cited
CCR
87633

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87633 Hospice Care of Terminally Ill Residents (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:
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POC Licensee agrees to submit a completed Hospice Care Plan to meet this regualtion by POC due date 03/21/25
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(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement was not met as evidenced by: Licensee did not have a care plan for R1 which poses a potential health safety and or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria WaltonTELEPHONE: (559) 246-0128
Shawna DoucetteTELEPHONE: (559) 580-4595

DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025

LIC809 (FAS) - (06/04)
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